Coronary Interventions Bioresorbable Scaffolds

Coronary Interventions Bioresorbable Scaffolds
How to Select the Most Appropriate Patient and Lesion to be Treated with
a Coronary Bioresorbable Vascular Scaffold
C ha ris C ostopoul o s, 1, 2, 3 A z e e m L a t i b 1, 2 a n d A n t o n i o Co l o m b o 1, 2
1. Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; 2. Interventional Cardiology Unit, EMO GVM Centro Cuore Columbus, Milan, Italy;
3. Department of Cardiology, Imperial College University, London, UK
Abstract
Bioresorbable vascular scaffolds (BVS) are an exciting novel treatment for coronary artery disease (CAD) as their eventual resorption
renders the artery free from a permanent metallic cage. Clinical trials regarding these novel devices have demonstrated promising
results, although their use in this context has largely been restricted to simple lesions. More recently, BVS use has expanded to patients
with more complex lesions including those with long diffuse disease, and results from several registries are awaited with regard to their
efficacy in ‘real-world’ patients. Although any patient who requires percutaneous treatment for CAD could benefit from BVS implantation,
there are certain cohorts of patients and lesions in whom BVS could be of particular benefit. In this review, we attempt to identify which
patient and lesion cohort is most suitable for treatment with these novel devices.
Keywords
Bioresorbable vascular scaffold, target lesion revascularisation, major adverse cardiac events
Disclosure: The authors have no conflicts of interest to declare.
Received: 5 August 2013 Accepted: 18 August 2013 Citation: Interventional Cardiology Review, 2013;8(2):90–2
Correspondence: Antonio Colombo, EMO GVM Centro Cuore Columbus, 48 Via M. Buonarroti, 20145 Milan, Italy. E: [email protected]
Although the introduction of metallic stents has revolutionised the
percutaneous treatment of coronary artery disease (CAD) and has
been demonstrated to improve clinical outcomes as compared with
plain old balloon angioplasty (POBA), the permanent presence of a
metallic cage that stays on the vessel wall beyond its intended purpose
of preventing acute recoil, is associated with a number of drawbacks.
The recent introduction of bioresorbable vascular scaffolds (BVS)
offers the potential of dealing with these drawbacks as these devices
allow positive remodelling and restoration of normal vasomotor vessel
function.1,2 They also offer the potential of reducing restenosis and
stent thrombosis rates because they tend to be more biocompatible
as compared with conventional metallic drug-eluting stents (DES),
whilst also maintaining access for coronary bypass grafting in the
future if required. Until recently, the use of BVS has largely been in
the context of clinical trials, but an increasing number of ‘real-world’
patients are being treated with these scaffolds. Despite the fact that
most, if not all, patients can be treated with these devices, it is clear
that certain patient cohorts have more to gain than others from
BVS use, especially if these innovative devices fulfil their expected
potential. In view of their higher cost and challenges in implantation
technique as compared with conventional DES, the selective use of
BVS is appropriate especially in the current climate.
Bioresorbable Vascular Scaffolds Available for
Clinical Use
Recent years have seen a huge expansion in the development of BVS
many of which are undergoing preclinical or clinical assessment. One
of these, the ABSORB™ BVS (Abbott Vascular, Santa Clara, California,
US) is currently available with the DESolve™ BVS (Elixir Medical,
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Sunnyvale, California, US) being available for clinical use later in the
year. The ABSORB BVS is made from semicrystalline poly-L-lactic acid
(PLLA) coated with an amorphous poly-D, L-lactide (PDLA) polymer
eluting everolimus. Degradation of the scaffold is mainly through
hydrolysis, a process that takes approximately two years to complete.
The efficacy of the currently used ABSORB BVS (revision 1.1) has
been assessed in the multicentre, single-arm ABSORB Cohort B trial,
which recruited 101 patients with single- or two-vessel de novo
disease, all of which received a 3 x 18 millimetre (mm) BVS. Patients
were divided into two groups for follow-up purposes with group 1
being assessed at six months and two years and group 2 at one and
three years, respectively. Scaffold area was shown to progressively
increase during follow-up with no differences in late lumen loss (LLL)
(0.29 ± 0.16 mm versus 0.25 ± 0.22 mm, p=0.439) being noted between
small vessels (<2.5 mm) and large vessels (≥2.5 mm) at two-year
angiographic follow-up.3 At 18 months follow-up in the entire cohort,
there were three non-ST elevation myocardial infarctions (MIs) and
four ischaemia-driven target lesion revascularisations (TLR).4 In the
ABSORB EXTEND study, aiming to recruit 1,000 patients, in which
the recruitment of patients with disease in smaller vessels (>2.0 mm)
as well as those with long lesions is allowed, the ischaemia-driven
TLR and major adverse cardiac events (MACE) rates at one-year has
been reported as 1.8 and 4.2 %, respectively. Definite/probable stent
thrombosis (ST) rate was 0.9 %.5 Data from the treatment of real-world
patients is also emerging. In the prospective, single-centre, BVS
Expand registry in which the liberal use of BVS is permitted with the
exception of patients with ST-elevation MI (STEMI) and restenotic
lesions, the use of BVS was associated with one MI and one non-target
vessel revascularisation (TVR) at 30-day follow-up in a cohort of
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The Most Appropriate Patient and Lesion to be Treated with a Coronary Bioresorbable Vascular Scaffold
131 patients.6 BVS has also been evaluated in the context of acute
coronary syndromes although meaningful clinical follow-up data is
not yet available.7,8 Other studies currently underway include the
ABSORB III and ABSORB IV studies that aim to compare ABSORB to
XIENCE PRIME™ Everolimus Eluting Stent (Abbott Vascular, Santa
Clara, California, US).
The DESolve bioresorbable scaffold is made from a PLLA-based
polymer eluting novolimus and has been designed to be fully resorbed
within two years. In the multicentre CE Mark DESolve Nx trial, which
enrolled 126 patients worldwide, quantitative coronary angiography
at six months demonstrated a LLL of 0.21 ± 0.34 mm with an increase
in scaffold area over the same interval (5.86>6.78 mm2, p≤0.001).
The incidence of MACE was 3.25 % with one cardiac death, one
target-vessel MI and two clinically indicated TLR. There were no
reported cases of ST.9 Following these results, DESolve has received
CE Mark approval and the scaffold is expected to be available for
commercial use in a variety of lengths and sizes later this year.
Use of Bioresorbable Vascular Scaffold in
Routine Clinical Practice
Although most studies to date have evaluated BVS implantation for
short, non-calcified lesions in moderately-sized vessels, it is likely
that these novel devices, assuming that they fulfil their full potential,
will offer most of their benefit in patients with more complex lesions
(see Table 1). Thus BVS use should not be restricted to patients with
simple (American Heart Association/ American College of Cardiology
[AHA/ACC] Type A or B) lesions as such patients would probably have
experienced similar benefits with the implantation of conventional
metallic DES. This of course does not mean that these patients
should not be treated with BVS since the absence of a permanent
implant and restoration of vasomotion can still be advantageous
as this may reduce the risk of very late ST whilst normal coronary
physiology is also returned. Patients with long segments of diffuse
disease, long occlusions requiring vessel reconstruction and those
requiring multivessel revascularisation can particularly benefit from
BVS implantation since stent length returns to zero after resorption
(see Figure 1). This is important not only because it permits subsequent
percutaneous treatment without the addition of more stent layers
whilst also keeping the option of coronary bypass graft surgery open,
but also because it can reduce late adverse events such as ST and
clinically significant restenosis, the risk of which rises with increasing
total stent length. Furthermore, in these patients any ‘jailed’ side
branches following BVS implantation are liberated as the scaffold
is resorbed. Thus BVS should also be considered for lesions that
involve side branches, which are too small for dilatation following
stent implantation. It is important to mention that when treating
patients with long disease to try and limit BVS overlap since currently
available devices have much thicker struts (≈150 micrometres [µm])
as compared with conventional DES. Thus in areas of overlap,
300 µm of BVS surround the vessel, which can impact significantly on
lumen area especially in smaller vessels. This can be achieved by first
deciding whether to implant proximal to distal or vice versa, something
that largely depends on whether greater accuracy is needed for the
proximal or distal landing zone. In cases where the proximal landing
zone is short it is best to implant first proximally whereas the opposite
should be performed with a short distal landing zone. Large overlap
can also be avoided by placing the balloon marker of the BVS about
to be implanted side-by-side with the platinum marker of the already
implanted BVS, since the platinum markers are within the BVS edges.
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Table 1: Bioresorbable Vascular Scaffold Use on the Basis of
Patient and Lesion Characteristics
Favour Bioresorbable
Vascular Scaffold
Young patient Use Bioresorbable
Vascular Scaffold
with Caution
STEMI
Avoid Bioresorbable
Vascular Scaffold
Lesions in vessel with diameter
<2.5 mm and >4.0 mm
Any lesion in vessels
Patient where DAPT
with diameter <6 months is preferred
>2.5 mm and ≤4.0 mm Long diffuse disease
especially in LAD
Long occlusion requiring
vessel reconstruction
Multivessel disease
DAPT = dual-antiplatelet therapy; LAD = left anterior descending; mm = millimetres; STEMI =
ST elevation myocardial infarction.
Figure 1: A Case of a Long Left Anterior Descending Disease
Treated with Bioresorbable Vascular Scaffolds
A
B
C
BVS 3.0 x 28 mm
C1
C2
C3
BVS 2.5 x 28 mm
C4
C1
C2
C3
SA 6.2 mm2
C4
SA 4.4 mm2
(A) Initial angiographic image, (B) Angiographic image following rotational atherectomy and
(C) Angiographic and intravascular images following BVS implantation.
BVS = bioresorbable vascular scaffold; mm2 = square millimetres; SA = scaffold area.
Figure 2: A Case of a Long Left Anterior Descending and
Diagonal Bifurcation Treated with Systematic Two-stenting
Using Bioresorbable Vascular Scaffolds
A
B
BVS 2.5 x 28 mm diagonal
B1
B2
Disease in LAD
and diagonal
BVS 3.0 x 28 mm
and 2.5 x 28 mm in LAD
B3
B1
B2
B3
Diagonal
SA 7.3 mm2
Bifurcation
SA 4.4 mm2
(A) Initial angiographic image and (B) Angiographic and optical coherence tomography
images following BVS implantation. BVS = bioresorbable vascular scaffold; LAD = left anterior
descending; mm2 = square millimetres; SA = scaffold area.
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Coronary Interventions Bioresorbable Scaffolds
Young patients are also attractive candidates for BVS for exactly the
same reasons as mentioned above. Patients that require a dedicated
two-stent technique for the treatment of a coronary bifurcation may
also fare better with a BVS especially when a mini-crush or T-stenting
technique is undertaken (see Figure 2). It is important when considering
BVS for this indication to ensure that the side branch diameter is
≥2.5 mm as this is the smallest BVS available, and that the main branch
can accommodate ≈450 µm of struts on the other side of the carina,
which will result after a mini-crush technique. Although BVS use in
this setting can be slightly challenging, it can be achieved by ensuring
adequate predilatation with a balloon of the same diameter as the BVS
intended to be implanted. This applies for any lesion to be treated with
BVS as it helps to ensure complete BVS expansion. The advantage of
using BVS for a dedicated two-stent strategy is that the ‘congestion’
of struts after a mini-crush technique is undertaken stops being an
issue as the scaffold undergoes hydrolysis. It is important to note here
that we do not advocate the use of a ‘culotte’ technique with BVS as
these result in relatively long segments of BVS overlap.
Although BVS can be used for most lesions, there are certain occasions
that these should be avoided or at least used with caution. However,
this does not include patients with heavily calcified lesions, as currently
available tools such as rotational atherectomy, scoring, cutting and
ultra-high pressure balloons can ensure that a calcified lesion is
well-prepared for BVS implantation. This is a principle that applies also
to conventional DES. In our experience, excellent results can be obtained
with BVS in such lesions when meticulous lesion preparation as well as
post-dilatation have been performed. Occasions where BVS use may not
be appropriate includes the treatment of lesions where vessel diameter
is <2.5 mm not only because a 2.25 mm BVS is not available but also
1.
2.
3.
Serruys PW, Onuma Y, Dudek D, et al., Evaluation of the
second generation of a bioresorbable everolimus-eluting
vascular scaffold for the treatment of de novo coronary
artery stenosis: 12-month clinical and imaging outcomes,
J Am Coll Cardiol , 2011;58:1578–88.
Haude M, Progress with Drug-Eluting Magnesium
Resorbing Stents (BIOTRONIK Dreams Program): DREAMS
2-Year Results, Presented at: Transcatheter Cardiovascular
Therapeutics (TCT) Conference, Miami, FL, US, 15 October
2012.
Diletti R, Farooq V, Girasis C, et al., Clinical and
intravascular imaging outcomes at 1 and 2 years after
implantation of absorb everolimus eluting bioresorbable
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4.
5.
because the thicker struts of currently available devices may lead to
significant lumen reductions. They should also not be used when vessel
diameter is >4.0 mm as the largest available BVS is 3.5 mm and the
maximum recommended balloon diameter that can be used for this is
4.0 mm (0.5 mm tolerance). In our opinion, they should also be used with
caution in STEMI until evidence with regards to BVS use in this context
becomes available. Finally, although the use of BVS can theoretically
allow shorter periods of dual-antiplatelet therapy (DAPT) due to the
inherent biocompatibility of the device, it is not yet known whether this
is possible or not. Thus, for patients in whom a DES is required and DAPT
cannot be given for more than six months it is perhaps judicious to use
a second generation metallic DES for which a shorter DAPT period is
possible such as the XIENCE PRIME or XIENCE V® (Abbott Vascular,
Santa Clara, California, US) or the Endeavor Resolute (Medtronic, Santa
Rosa, California, US).
Conclusion
BVS have the potential of revolutionising the percutaneous treatment
of CAD as their greater biocompatibility and eventual resorption
offer the possibility of further improving clinical outcomes whilst
maintaining the future option of further revascularisation if necessary.
In our experience, BVS can be used in a wide-range of lesions
with good procedural and early outcome results. Patients that may
especially benefit from this technology include those with multivessel
disease, diffusely diseased vessels, bifurcation lesions and those of
younger age. They should, however, be avoided in patients with too
large (>4.0 mm) or too small (<2.5 mm) vessels for currently available
devices. They should also be used with caution in patients with STEMI
and in those that may require shorter DAPT durations until further
evidence becomes available. n
vascular scaffolds in small vessels. Late lumen
enlargement: does bioresorption matter with small
vessel size? Insight from the ABSORB cohort B trial, Heart,
2013;99:98–105.
Serruys PW, Onuma Y, on behalf of the ABSORB A & B
investigators, ABSORB Cohort B: 6 m, 12 m, 18 m and 24 m
follow-up, Presented at: PCR focus group on bioresorbable
vascular scaffolds, Rotterdam NL, The Netherlands,
8–9 March 2012.
Serruys PW, BVS Extend: An Interim Report on the
12-Month Clinical Outcomes from the First 450 Patients
Registered, Presented at: EuroPCR, Paris, France, 21–24
May 2013.
6.
7.
8.
9.
Van Geuns R, BVS Expand: First result of wide clinical
applications of Bioresorbable Vascular Scaffold, Presented
at: EuroPCR, Paris, France, 21–24 May 2013.
Dudek D, Rzeszutko A, Lekston A, et al., Bioresorbable
Vascular Scaffolds (BVS) in Patients with Acute Coronary
Syndrome. The Muticenter Registry in Poland: POLAR ACS,
Presented at: EuroPCR, Paris, France, 21–24 May 2013.
Widimsky P, Bioresorbable vascular scaffolds in acute
STEMI: Prague-19 study, Presented at: EuroPCR, Paris,
France, 21–24 May 2013.
Abizaid A, First report on the Pivotal DESolve
Nx trial, Presented at: EuroPCR, Paris, France,
21–24 May 2013.
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